Central Nervous System Infections

Central Nervous System Infections

Definition

The central nervous system, or CNS, comprises the brain, the spinal cord, and associated membranes. Under some circumstances, bacteria may enter areas of the CNS. If this occurs, abscesses or empyemas may be established.

Description

In general, the CNS is well defended against infection. The spine and brain are sheathed in tough, protective membranes. The outermost membrane, the dura mater, and the next layer, the arachnoid, entirely encase the brain and spinal cord. However, these defenses are not absolute. In rare cases, bacteria gain access to areas within the CNS.

Bacterial infection of the CNS can result in abscesses and empyemas (accumulations of pus). Abscesses have fixed boundaries, but empyemas lack definable shape and size. CNS infections are classified according to the location where they occur. For example, a spinal epidural abscess is located above the dura mater, and a cranial subdural empyema occurs between the dura mater and the arachnoid.

As pus and other material from an infection accumulate, pressure is exerted on the brain or spinal cord. This pressure can damage the nervous system tissue, possibly permanently. Without treatment, a CNS infection is fatal.

Causes and symptoms

Typically, bacterial invasion results from the spread of a nearby infection; for example, a chronic sinus or middle ear infection can extend beyond its initial site. Bacteria may also be conveyed to the CNS from distant sites of infection by the bloodstream. In rare cases, head trauma or surgical procedures may introduce bacteria directly into the CNS. However, the source of infection cannot always be identified.

Specific symptoms of a CNS infection hinge on its exact location, but may include severe headache or back pain, weakness, sensory loss, and a fever. An individual may report a stiff neck, nausea or vomiting, and tiredness or disorientation. There is a potential for seizures, paralysis, or coma.

Diagnosis

Physical symptoms, such as a fever and intense backache or a fever, severe headache, and stiff neck, raise the suspicion of a CNS infection. Blood tests may indicate the presence of an infection but do not pinpoint its location. CT scans or MRI scans of the brain and spine can provide definitive diagnosis, with an MRI scan being the most sensitive. A lumbar puncture and analysis of the cerebrospinal fluid can help diagnose an epidural abscess; however, the procedure can be dangerous in cases of subdural empyema.

Treatment

A two-pronged approach is taken to treat CNS infections. First, antibiotic therapy against an array of potential infectious bacteria is begun. The second stage involves surgery to drain the infected site. Although some CNS infections have been resolved with antibiotics alone, the more aggressive approach is often preferred. Surgery allows immediate relief of pressure on the brain or spinal cord, as well as an opportunity to collect infectious material for bacterial identification. Once the bacterial species is identified, drug therapy can be altered to a more specific antibiotic. However, surgery may not be an option in some cases, such as when there are numerous sites of infection or when infection is located in an inaccessible area of the brain.

Prognosis

The fatality rate associated with CNS infections ranges from 10% to as high as 40%. Some survivors experience permanent CNS damage, resulting in partial paralysis, speech problems, or seizures. Rapid diagnosis and treatment are essential for a good prognosis. With prompt medical attention, an individual may recover completely.

Prevention

Treatment for pre-existing infections, such as sinus or middle ear infections, may prevent some cases of CNS infection. However, since some CNS infections are of unknown origin, not all are preventable.

Key terms

Arachnoid — One of the membranes that sheathes the spinal cord and brain; the arachnoid is the second-layer membrane.

Cerebrospinal fluid — Fluid that is normally found in the spinal cord and brain. Abnormal levels of certain molecules in this fluid can indicate the presence of infection or damage to the central nervous system.

CT scan (computed tomography) — Cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures.

Dura mater — One of the membranes that sheathes the spinal cord and brain; the dura mater is the outermost layer.

Lumbar puncture — A procedure in which a needle is inserted into the lower spine to collect a sample of cerebrospinal fluid.

MRI (magnetic resonance imaging) — An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.

Other topics covered include cerebrospinal fluid analysis, the pathogenesis and pathophysiology of bacterial central nervous system infections, the principles of antimicrobial therapy, and chapters on specific disease entities, including meningitis and HIV.

Surveillance is based on systematic microbiologic screening of all patients referred to the emergency departments of regional hospitals for suspected community-acquired central nervous system infections or fever and headache with a history of tick bite in the past 6 weeks.

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